RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03235
BRANCH OF SERVICE:  army 	SEPARATION DATE:  200610014

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Bradley Systems Maintainer, medically separated for “low back pain” and “bilateral knee pain,” rated 10% each, with a combined disability rating of 20%. 

CI CONTENTION:  Review all conditions.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20060821	VARD - 20060410	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Degenerative Disc Disease of the Thoracolumbar Spine	5242	20%	20051116	
Bilateral Knee Pain	5099-5003	10%	Residuals of Degenerative Joint Disease, Right Knee	5010-5260	NSC	20051116	
			Residuals of Degenerative Joint Disease, Left Knee	5010-5260	NSC	20051116	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began during annual training in June 2003 after he hyperextended his back while maneuvering rough terrain in an M-88 tank recovery vehicle. The CI was able to return to his National Guard technician job in April 2005 after his release from active duty.  In October 2005, MRI studies showed evidence of degenerative disc disease at the L5-S1 level.  

At the 16 November 2005  VA Compensation and Pension (C&P) general examination, 11 months before separation, the CI reported mid and low back pain with easy fatigability and stiffness.  Flare-ups were reported four times a week lasting the rest of the day.  He reported 2 days of lost time in the previous 12 months due to pain.  Physical examination showed a normal posture and gait.  Lumbar spine flexion was 60 degrees with a combined range of motion (ROM) of 200 degrees with pain at the extremes of movements.  The CI was unable to perform repetitive use due to the pain.  There was no objective evidence of painful motion, spasm, or weakness.  There was tenderness over the lumbar spine and both sacroiliac regions.  There were no postural abnormalities.

During the 5 June 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported constant back pain.  Physical examination showed a normal gait and minimal pain with flexion, extension, rotation, and side-to-side movement.  No measurements were provided.  

The 5 June 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic low back pain recalcitrant to physical therapy (PT), chiropractic treatment, epidurals, medication, rest, and profile restriction.  Physical examination showed a normal gait.  On 13 June 2006, 4 months prior to separation, lumbar flexion was 65 degrees and combined ROM was 165.  Repetition was limited by pain.  

At the 3 April 2007 VA C&P spine examination, 6 months after separation, the CI reported pain rated 5-6/10 most of the time.  Flare-ups with prolonged sitting or repetitive motion a couple of times a week were reported.  There were no incapacitating episodes.  Physical examination showed thoracolumbar ROM measurements with flexion of 90 degrees (normal) and combined ROM of 240 degrees (normal) with pain throughout the ROM.  The CI had a widened stance and there were mildly palpable spasms at L1/L2 with tenderness at S1.  There was no increased pain or change in ROM with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbar spine strain), citing combined passive ROM equal to 170 degrees.  The VA rated the back condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of 60 degrees and combined ROM of 200 degrees.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB PT examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  The C&P spine examination also supported a 10% rating for the presence of painful motion with full ROM.  The panel noted the C&P general examination specified the ROM for the lumbar spine and not the thoracolumbar spine specified by the VASRD (§4.71a, Plate V).  The lumbar spine ROM was reported as 60 degrees of flexion which is considered normal (60 is normal for isolated lumbar flexion). This VA examination’s probative value was also judged to be compromised by its remoteness (11 months) prior to the date of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 10%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to the STR and MEB NARSUM, the CI’s bilateral knee condition began in 1996.  No injury or trauma was indicated.  The CI was mobilized from September 2003-March 2005.  X-rays on 23 May 2005 were completed due to complaints of chronic pain.  There was no joint effusion, joint spaces appeared normal, and there were no significant degenerative changes in either knee.  At the 27 June 2005 primary care appointment the CI reported chronic pain in his knees.  On examination there was no edema, no inflammation, and ROM was reported as normal.  

At the 11 August 2005 family practice appointment the CI reported intermittent knee pain, right greater than left “for years” but worse lately.  He denied trauma.  On examination there was full ROM, no pain with varus/valgus stress, and no pain with internal or external rotation.  There was discomfort at the medial knee joint and under the patella with motion.  Bilateral knee X-rays on 11 August 2005 were normal.  An MRI of the right knee on 17 August 2005 revealed posteromedial patella bone contusion or subchondral degenerative cyst.  Otherwise the MRI was unremarkable.  At the 17 October 2005 physical medicine and rehabilitation clinic appointment the CI reported constant knee pain, right greater than left.  There was minimal tenderness and ROM was within normal limits.

At the 16 November 2005 VA C&P examination, 11 months before separation, the CI reported bilateral knee pain with stiffness and redness and “it can lock up and pop.”  Physical examination showed a normal gait.  Each knee extended to 0 degrees and flexed to 140 degrees (normal) with pain at the extreme of flexion.  Following repetitive use there was no change in ROM of either knee.  There was tenderness laterally and medially over the joint lines of the knees as well as over both patellae.  

During the 5 June 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported swelling and pain in both knees.  Physical examination showed full extension and flexion without pain.  There was no effusion.  There was mild pain of the left lateral knee with medial stressing.   The 5 June 2006 MEB NARSUM examination noted complaints of bilateral knee pain and occasional swelling with excessive activity.  With inactivity the CI reported mild pain.  The examiner stated “his knees maintain good ROM and do not give out.”  Physical examination showed a normal gait, no effusion and full extension and flexion without pain.  

At the 13 June 2006 PT MEB ROM examination the left knee ROM was flexion of 135 degrees  and extension -1 degrees (normal 0); right knee ROM was flexion of 135 degrees and extension of -2 degrees.  There was no pain with motion noted.  An MRI of the right knee on 15 June 2006 showed degenerative chondromalacia patella.  An MRI of the left knee on 16 June 2006 showed findings consistent with intrasubstance degeneration with no definite meniscal tear and mild chondromalacia of the patella.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the right knee condition with the left knee condition and applied a single 10% rating (coded 5099-5003), citing X-ray evidence and full ROM.  Initially the VA did not service connect the knees.  However, on appeal and after a decision review officer decision, the VA rated the left and right knee conditions 10% each, both coded 5010-5260 (arthritis due to trauma-leg, limitation of flexion of), based on the C&P examination, MRI studies 4 months before separation, and treatment records, citing functional impairment caused by painful motion.

In this case, both knees were considered to fail retention standards.  They were implicated by the NARSUM and the commander’s statement and both were profiled.  Panel members agreed the evidence reasonably justified that the functional limitations of the bilateral knees contributed to the CI’s inability to perform his military duties and were separately unfitting.  The panel then considered an appropriate disability rating.

The panel closely reviewed the evidence and determined a bilateral 10% rating under the provisions of 5003 was warranted based on the MRI evidence of with involvement of 2 or more major joints and no objective evidence of limited painful motion.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.  

Contended PEB Condition:  Hyperlipidemia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement, nor judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bilateral knee condition, the panel recommends no change in the PEB adjudication.  In the matter of the contended hyperlipidemia condition, the panel agrees that it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.   

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170327, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006220, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure